PFD Response Tracker

Prevention of Future Deaths

Total: 1,340 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,340

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

1 report include a non-response confirmed by the Chief Coroner. Show only confirmed

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1,340 reports · Page 27 of 27

Date	Deceased	Addressee(s)	Status	Responses
3 Oct 2013	Ishmail Kubilay The Prison Ombudsman's clinic review identified healthcare deficiencies with national implications, but the specific recommendations are truncated in …	Department of Health and Social …	Historic (No Identified Response)	0/1
26 Sep 2013	Betty Grace Payne Insufficient information sharing about vulnerable individuals with the Fire Service and a lack of training for Local Authority …	Pembrokeshire County Council Hall Carmarthenshire County Council County Hall	Historic (No Identified Response)	0/2
26 Sep 2013	Joan Farran The provided text is truncated and does not clearly state the specific concerns identified by the coroner.	Safeguarding Adults Board	Historic (No Identified Response)	0/1
25 Sep 2013	David Selman An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not …	South Central Ambulance Service	Historic (No Identified Response)	0/1
24 Sep 2013	Linda Hudson Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse …	Tees, Esk and Wear Valleys …	Historic (No Identified Response)	0/1
23 Sep 2013	Yvonne Sydney Annie Perry A lack of robust processes for tracking radiology reports led to critical delays in patient care. Additionally, GPs …	Care Quality Commission	Historic (No Identified Response)	0/1
23 Sep 2013	Sally King The provided concerns text is too truncated to identify specific safety issues.	Care Quality Commission	Historic (No Identified Response)	0/1
19 Sep 2013	Tripta Rani Kumar A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly …	Queen’s Hospital	Historic (No Identified Response)	0/1
19 Sep 2013	Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet Neonatal units may lack awareness of cardiac tamponade as a complication of TPN feeding and are not sharing …	Birmingham Woman’s Hospital and South-West … SENAT	Historic (No Identified Response)	0/2
17 Sep 2013	Alva Jullien A lack of home assessment and poor communication between health professionals led to an unnecessary prolonged hospital stay, …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
17 Sep 2013	Neil Richard Clark A patient who had attempted overdose and undergone a mental health assessment was able to leave an Ambulatory …	Jurys Inn Birmingham	Historic (No Identified Response)	0/1
17 Sep 2013	Margaret Theresa Corrigan Ineffective communication, a missed fracture diagnosis in the Emergency Department, and inappropriate ward placement for medical issues contributed …	Stockport NHS Foundation Trust	Historic (No Identified Response)	0/1
16 Sep 2013	George Renshaw Brown A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to …	Manchester Clinical Commissioning Group Fentons Solicitors Bromleys Solicitors Mayfield Care Home Trafford Borough Council Care Quality Commission	Historic (No Identified Response)	0/6
16 Sep 2013	Rachael Dallison The provided concerns text is too truncated to identify specific safety issues.	Staffordshire County Council Commissioner for Transport	Historic (No Identified Response)	0/2
12 Sep 2013	Matthew Dunham Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and …	Norfolk and Suffolk NHS Foundation …	Historic (No Identified Response)	0/1
11 Sep 2013	Caroline Lee Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform …	University Hospital Coventry and Warwickshire	Historic (No Identified Response)	0/1
10 Sep 2013	David Douglas Hackman After a previous overdose attempt, a patient undergoing mental health assessment in a hospital unit was able to …	NHS England	Historic (No Identified Response)	0/1
9 Sep 2013	John Michael Bailey	Department of Health and Social …	Historic (No Identified Response)	0/1
9 Sep 2013	Ricky Anderson Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, …	Kent and Medway NHS	Historic (No Identified Response)	0/1
4 Sep 2013	Michael Irlam A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates …	Improving Access to Psychological Therapies Trafford Crisis Resolution and Home …	Historic (No Identified Response)	0/2
30 Aug 2013	Jessica Ashton-Pyatt The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing …	United Lincolnshire Hospitals NHS Trust	Historic (No Identified Response)	0/1
30 Aug 2013	May Gibson The care home exhibited widespread systemic failures, including inadequate assessments, poor care planning, insufficient risk management, and a …	Herries Lodge Care Home	Historic (No Identified Response)	0/1
27 Aug 2013	Muniza Mehrban This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating …	Jesta Capital Corporation	Historic (No Identified Response)	0/1
23 Aug 2013	Jill Sinson The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, …	Beeston Health Centre	Historic (No Identified Response)	0/1
20 Aug 2013	Mohammed Chaudhury The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient …	Care Quality Commission King’s College Hospitals NHS Foundation …	Historic (No Identified Response)	0/2
20 Aug 2013	Nicola Matthews Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff …	South London and Maudsley NHS …	Historic (No Identified Response)	0/1
16 Aug 2013	Keward Guy Domonic Harding An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline …	Community Mental Health Team	Historic (No Identified Response)	0/1
14 Aug 2013	Jordan Buckton Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate …	National Offender Management Service Dorset Healthcare University NHS Foundation …	Historic (No Identified Response)	0/2
13 Aug 2013	Vera Lillian Steel A frail, bedbound resident fatally burned herself while smoking. Care homes should be encouraged to provide fire-protective aprons …	Care Quality Commission South East England Fire and …	Historic (No Identified Response)	0/2
9 Aug 2013	Ronald Sherlock Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations …	Serco	Historic (No Identified Response)	0/1
8 Aug 2013	Dimitar Shtarbov Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also …	East Lincolnshire Clinical Commissioning Group South Lincolnshire Clinical Commissioning Group	Historic (No Identified Response)	0/2
8 Aug 2013	Matthew Thomas Hamilton A narrow footpath lacked a barrier, allowing children to emerge suddenly into traffic, compounded by restricted vision from …	Cumbria County Council	Historic (No Identified Response)	0/1
7 Aug 2013	Jean Miller District nurses failed to baseline a patient's wound, did not involve tissue viability specialists, and did not routinely …	Pennine Care Trust	Historic (No Identified Response)	0/1
7 Aug 2013	Ethel Smith Leese Chaotic address verification procedures by the hospital post-discharge led to significant issues with the monitoring of Mrs. Leese's …	Stafford Hospital	Historic (No Identified Response)	0/1
5 Aug 2013	Alan Smith A co-worker lacked specific training for working at height, and generic risk assessment forms and method statements were …	Carrington Doors	Historic (No Identified Response)	0/1
1 Aug 2013	David George White	Regeneration and Environment	Historic (No Identified Response)	0/1
1 Aug 2013	Michael James Thornton	Somerset County Council Taunton Couthy Hall	Historic (No Identified Response)	0/2
1 Aug 2013	Annie Rose Gibson	Saga Homecare	Historic (No Identified Response)	0/1
30 Jul 2013	Derek Edward Bartlett Twivey	Fairlight Nursing Home	Historic (No Identified Response)	0/1
30 Jul 2013	Phillip Pratt	Western Sussex Hospitals NHS Trust	Historic (No Identified Response)	0/1

Ishmail Kubilay